©2015-2019 Caring Canines Therapy Dogs of Southern Vermont, Inc.

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Caring Canines Therapy Dog Club of Southern Vermont

Application for Membership

 

 Regular Member ($35.00)           Household Membership ($50.00)           Supporting Member ($20.00)

Payment of dues will be collected upon successful completion of dog/handler evaluation.

 

Name:________________________________________________________________________________

 

Address:______________________________________________________________________________

 

City / State/ Zip :________________________________________________________________________

 

Telephone: _________________________________ Fax: ________________________________________

 

E-Mail: _______________________________  Breed of Dog:______________________________________

 

Name: ___________________________________ Date of Birth:___________________________________

 

Sex: _____________________________________  Color:________________________________________

 

Number of Dogs in the household _________________ Is your dog spayed / neutered? Yes          No

 

In order to help us better understand you and your dog, please complete as much of the information below as you are comfortable with. If not applicable, please indicate with ‘NA’

 

How did you become aware of Caring Canines?__________________________________________________

 

_______________________________________________________________________________________

 

List other clubs to which you currently belong:___________________________________________________

 

_______________________________________________________________________________________

 

On what club committees have you served and/or what club related activities have you been involved with?___

 

_______________________________________________________________________________________

 

List any dog related areas of interest:__________________________________________________________

 

________________________________________________________________________________________

 

If accepted as a member of the C.C.T.D.C. of S.VT.,  what would you most look forward to?________________

 

________________________________________________________________________________________

 

What is your perception of a therapy team and tell us what type of visits you are interested in doing? (Nursing home, Adult Day Care, Children’s Reading Program, Animal Assisted Therapy, Other.) Can you commit to at least 5 visits a year? _____________________________________________________

 

________________________________________________________________________________________

 

Why do you believe that your dog is suited to therapy work: _________________________________________

 

_________________________________________________________________________________________

 

List any activities that your dog has participated in:___________________________________________

 

_________________________________________________________________________________________

 

Does your dog have a Canine Good Citizen certificate (CGC)? ______________________________________

 

Describe the level of your dog’s obedience experience: ____________________________________________

 

________________________________________________________________________________________

 

Has your dog ever bitten a human being?                                          Yes                                No

Is your dog hand shy?                                                                        Yes                                No

Has your dog ever been involved in a dog fight?                                Yes                                 No

Is your dog shy or nervous around crowds of people (describe):______________________________________

 

________________________________________________________________________________________

 

Does your dog get along well with children (describe)?___________________________________________

 

__________________________________________________________________________________________

 

How does your dog act with multiple dogs and people in the room?_____________________________________

 

_________________________________________________________________________________________

 

How does your dog handle stress (describe):______________________________________________________

 

_________________________________________________________________________________________

 

 

What do you do as a handler to address this?_____________________________________________________

 

_________________________________________________________________________________________

 

What types of collars and leashes do you use?_____________________________________________________

 

__________________________________________________________________________________________

Describe you dog (check all that apply):

 

    Adaptable        Outgoing       Timid       Shy               Hyper         Friendly           Calm          Reliable

 

 

Are you interested in participating in workshops offered by Caring Canines?_______________________________

 

_________________________________________________________________________________________

 

 

Do you belong to another Therapy Dog organization? If yes which one: ______________________________

 

 

 

Signature of Applicant _________________________________________ Date _______________________

 

 

Please mail completed application to:

Linda Shelvey

713 Upper Cold River Rd.

Shrewsbury, Vt. 05738

lpurdyshel@gmail.com